Pulmonary embolism medical therapy: Difference between revisions
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==[[Heparin]]== | ==Parenteral Anticoagulants]] | ||
===[[Heparin]]=== | |||
* Heparin binds to antithrombin and inactivates thrombin, factors IIa, Xa, IXa, XIa and XIIa; binds to heparin cofactor II and inactivates factor IIa; and binds to factor IXa and inhibits factor X activation. | |||
* Unfractionated heparin is mainly used in patients with known renal insufficiency or those who need close monitoring for bleeding, as activated partial thromboplastin time can be checked every 2 hours and doses adjusted. | |||
* The apparent biologic half-life of heparin increases from approximately 30 min after an IV bolus of 25 units/kg, to 60 min with an IV bolus of 100 units/kg, to 150 min with a bolus of 400 units/kg. | |||
* Efficacy of heparin in the initial treatment of [[DVT]] or [[PE]] is highly dependent on dosage. | |||
* Initial dosing of IV heparin for VTE is either weight-based (80 units/kg bolus and 18 units/kg/h infusion) or administered as a bolus of 5,000 units followed by an infusion of at least 32,000 units/d. | |||
* If heparin is given subcutaneously for treatment of VTE, there are at least two options: (1) an initial IV bolus of 5,000 units followed by 250 units/kg twice daily; or (2) an initial subcutaneous dose of 333 units/kg followed by 250 units/kg twice daily thereafter. | |||
* The dose for [[acute coronary syndrome]] is lower as compared to the treatment of [[DVT]] | |||
* The main side effects are heparin-induce thrombocytopenia and osteoporosis. | |||
* One major advantage of heparin is that the anticoagulant effects can be reversed with IV protamine sulfate. | |||
[[Subcutaneous]] [[LMWH|Low molecular weight heparin]], [[fondapariux]] or or [[Intravenous]] heparin is indicated in hemodynamically stable patients. | [[Subcutaneous]] [[LMWH|Low molecular weight heparin]], [[fondapariux]] or or [[Intravenous]] heparin is indicated in hemodynamically stable patients. | ||
===Dosages=== | ===Dosages=== | ||
Revision as of 18:52, 22 May 2012
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Pulmonary Embolism Microchapters |
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Diagnosis |
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Pulmonary Embolism Assessment of Probability of Subsequent VTE and Risk Scores |
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Treatment |
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Follow-Up |
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Special Scenario |
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Trials |
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Case Studies |
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Pulmonary embolism medical therapy On the Web |
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Directions to Hospitals Treating Pulmonary embolism medical therapy |
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Risk calculators and risk factors for Pulmonary embolism medical therapy |
Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
In most cases, anticoagulant therapy is the mainstay of treatment. For details, visit treatment approach. This chapter discusses the recommended doses.
Treatment Protocol[1]
Stabilize the patient
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Initial Treatment options (≤5 Days)
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| Long term treatment (≥3 Month) (INR target, 2.0-3.0) | |||||||||||||||||||
| Extended treatment (Indefinite) (INR target, 2.0-3.0 OR 1.5-1.9) | |||||||||||||||||||
==Parenteral Anticoagulants]]
Heparin
- Heparin binds to antithrombin and inactivates thrombin, factors IIa, Xa, IXa, XIa and XIIa; binds to heparin cofactor II and inactivates factor IIa; and binds to factor IXa and inhibits factor X activation.
- Unfractionated heparin is mainly used in patients with known renal insufficiency or those who need close monitoring for bleeding, as activated partial thromboplastin time can be checked every 2 hours and doses adjusted.
- The apparent biologic half-life of heparin increases from approximately 30 min after an IV bolus of 25 units/kg, to 60 min with an IV bolus of 100 units/kg, to 150 min with a bolus of 400 units/kg.
- Efficacy of heparin in the initial treatment of DVT or PE is highly dependent on dosage.
- Initial dosing of IV heparin for VTE is either weight-based (80 units/kg bolus and 18 units/kg/h infusion) or administered as a bolus of 5,000 units followed by an infusion of at least 32,000 units/d.
- If heparin is given subcutaneously for treatment of VTE, there are at least two options: (1) an initial IV bolus of 5,000 units followed by 250 units/kg twice daily; or (2) an initial subcutaneous dose of 333 units/kg followed by 250 units/kg twice daily thereafter.
- The dose for acute coronary syndrome is lower as compared to the treatment of DVT
- The main side effects are heparin-induce thrombocytopenia and osteoporosis.
- One major advantage of heparin is that the anticoagulant effects can be reversed with IV protamine sulfate.
Subcutaneous Low molecular weight heparin, fondapariux or or Intravenous heparin is indicated in hemodynamically stable patients.
Dosages
Following doses are recommended[2]:
- Low molecular weight heparin
- Enoxaparin : 1 mg/Kg body weight (twice daily).
- Tinzaparin : 175 U/Kg body weight (once daily).
- Factor Xa Inhibitors/Fondaparinux
- Patient weighing less than 50 Kg (110 lb) : 5 mg (once daily).
- Patient weighing 50 Kg (110 lb) to 110 Kg (220 lb): 7.5 mg (once daily).
- Patient weighing more than 100 Kg (220 lb) : 10 mg (once daily).
- Unfractionated heparin
- Loading Dose: 80 IU/Kg or 5000 IU
- Mantainace Dose: 18 IU/Kg/Hr to achieve a target aPTT 1.5 to 2.5 times the normal value.
Warfarin
- The recommended therapeutic INR on warfarin is 2.0-3.0.
References
- ↑ Agnelli G, Becattini C (2010). "Acute pulmonary embolism". N Engl J Med. 363 (3): 266–74. doi:10.1056/NEJMra0907731. PMID 20592294.
- ↑ Raschke RA, Gollihare B, Peirce JC (1996). "The effectiveness of implementing the weight-based heparin nomogram as a practice guideline". Arch Intern Med. 156 (15): 1645–9. PMID 8694662.